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Authors : Dr. Prajwalit Prakash Kende, Dr. Divya Ramakant Kanodia, Dr. Jayant Shivaji Landage.

Abstract

Dental injuries are very common. Avulsion of a tooth is a grievous injury and ranges from 0.5-16% among the traumatic injuries, occurring most commonly in maxillary anterior teeth. Replantation of avulsed teeth is a standard procedure and the choice of treatment having certain limitations. In this article we intend to present the management of avulsed maxillary incisors already treated with a root canal and post core build up by replantation after 12 hrs in a 12 year old boy with a review of literature.

Introduction

Maxillofacial trauma is a common presentation in accident and emergency departments of hospitals occurring in approximately 5 to 33% of patients experiencing severe trauma. 1Traumatic dental injuries occur with great frequency in 6-34% of children aged 8-15 years who experience damage to their permanent teeth. 2“When the tooth is removed from its socket, consequence of a trauma, and the surrounding structures as periodontal ligament and neurovascular bundle injure, the situation is named as tooth avulsion.”World Health Organization's classification system modified by Andreasen. 3Tooth avulsion is seen twice more frequently in males than in females.As early as 400 BCE Hippocrates suggested that displaced teeth should be replaced and splinted to adjacent teeth with wire.Till date different treatment modalities have been reported in the literature.4
This article aims to present a case reporton the replantation of a previously endodontically treated avulsed permanent incisor in a 12year old boy after 12 hourand mulling on alternate treatment strategies, future directions and recent research on the subject of the avulsed tooth.

Case report

A 12 year old boy reported to Department of Maxillofacial & Oral Surgery, GDC&H, Mumbai with a chief complaint of avulsed tooth from upper anterior region due to a fall 12 hours back with pain and swelling in the same region. Figure 1

The patient gave history of fall from stairs in his house 12 hours back. No history of unconsciousness, vomiting or ear, nose and throat bleeding. One tooth from the upper anterior region came out from the socket along with bleeding. His parent in an apprehensive state of mind placed the tooth back into the empty socket. The bleeding immediately stopped.  The patient also complained of moderate pain in the same region and took over the counter analgesics to relive the pain. There was a mild swelling associated with the same region. The patient gave history of root canal treatment done in the same tooth 8 months back with some filling over it. The patient did not report any significant past medical,family personal and drug or allergy history.

On examination the patient had extra oral swelling which was measuring 1cm x 1cm, tender on palpation, soft in consistency and diffuse in nature. Intraorally the 21 was grade III mobile. The tooth was root canal treated with a post and core done. Also, 11 had an Ellis Class II fracture.The patient was advised an Intra Oral PeriApical View (IOPA) with 11 and 21 along with routine blood investigation.The IOPA suggested that 21 wasendodontically treated with a radio-opaque filling done and 11 had a Ellis Class II fracture.Routine blood investigations were within normal limits. An endodontic opinion was sought for 11 and 21.

Thus, the treatment plan wasmade as per the International Association of Dental Traumatology guidelineto replant the avulsed tooth. 5 Under all aseptic precautions, the tooth was gently removed from the socket under local anesthesia. (Figure 2, Figure 3 and Figure 4) It was carefully cleaned with normal saline keeping the periodontal fibers intact and stored in the same while the IOPA radiograph of the empty socket was taken. The radiograph showed an empty clean socket with no other hard tissue injury and normal trabecular pattern.(Figure 5) The socket was cleaned with normal saline. With slight finger pressure, the tooth was gently replaced in its anatomic position, into thealveolar socket. The tooth was repositioned after checking the normal overjet and overbite (Figure 6 and Figure 7).Inter maxillary fixation was done from 13 to 23using an Erich arch bar and 24 gauge stainless steel wire. (Figure 8)The patient was instructed to avoid biting with the splinted teeth and to follow a strict soft and liquid diet and maintaining a goodoral hygiene. A post operative course of antibiotics, anti-inflammatory and analgesics was prescribed. The patient was asked to follow up weekly to check the mobility of the tooth, overjet, overbite and oral hygiene.
After 2 weeks mobility was clinically observed with 21 and so the splint was kept for another 2 weeks. After 4 weeks no mobility was clinically observed. (Figure 9) An intra oralperi apical radiograph was taken which revealed normal bone healing surrounding the tooth, intact lamina dura without any periapical pathology.(Figure 10) The patient was the referred to The Dept. of Prosthodontics for permanent restoration with 21 and 11. (Figure 11 and Figure 12)
The patient was followed up for 6 months after which he lost to follow up. 

     
Figure 1: Pre-operative frontal view 

Figure 2: Intra Oral view showing the empty socket.

Figure 3: Buccal side of avulsed 21

     
Figure 4: Palatal view of avulsed 21 showing a post and core build up. Figure 5: IOPA showing the empty socket of 21 and Ellis Class II fracture with 11. Figure 6: 21 is replanted into the socket.
     
Figure 7: Replanted 21 in occlusion. Figure 8: Erich Arch bar fixation is dne from 13 to 23. Figure 9: Post operative View showing the replanted tooth in occlusion after 4 weeks.
     
Figure 10: Post operative IOPA after 4 weeks. Figure 11: Acrylic Crown for 11 and 21 showing overbite. Figure 12: Acrylic crowns for 21 abd 22 showing overjet.

Discussion

Avulsion of a tooth accounts for between 0.5 to 3% of dento-alveolar trauma to permanent teeth. 6 In the most severe scenarios, the tooth or teeth are lost, e.g. not replanted, or extracted due to the failure of the replanted tooth. The latest UK national surveyreported a prevalence of 1.2% of fifteen-year old children with missing anterior teeth as a result of trauma. 2More than 70% of all traumatic oral injuries occur in childhood and for this age group the mouth was the fourth most common site of injury, despite occupying only 1% of the body surface.2Tooth avulsion is defined as total displacement of the tooth out of its alveolar socket. Avulsion of permanent teeth occurs most often in children 7 to 9 years old, an age when the relatively resilient alveolar bone provides only minimal resistance to extrusive forces, and the maxillary central incisors are themost commonly affected teeth.6
Avulsion occurs as a result of blunt trauma. The force acting on the tooth should be sufficient enough to overcome the attachment between the affected tooth and the periodontal ligament within the alveolar socket but not enough to fracture the tooth or the surrounding bone. When a tooth is avulsed attachment damage and pulp necrosis occurs. The tooth is ‘separated’ from the socket, mainly due to the tearing of the periodontal ligament with damage to the neurovascular bundle which leaves viable periodontal ligament cells on most of the root surface. In addition, due to the crushing of the tooth against the socket a small localized cemental damage also occurs.4
A root canal treated tooth eventually becomes brittle and in a situation of trauma one would expect the tooth to fracture. In the case presented it did not fracture and was completely displaced out of its socket as; i The trauma was blunt in nature; ii The patient was only 12 years old so the surrounding bone was still not dense. It was resilient in nature; iii Root canal treatment was done only 8 months back.
Management of permanent avulsed teeth is always challenging however if managed properly, following the guidelinesthe avulsed tooth with vital or avital periodontal ligament can be replanted and will remain functional for some time. 5
Favorable healing of an avulsed tooth requires quick emergency intervention followed by evaluation and deciding the treatment plan.In clinical studies, teeth replanted within 5 minutes after avulsion had the best prognosis and the chance of pulpal and periodontal healing was inversely related to the stage of root development and the period of dry storage. 7,8,9,10In the optimal scenario the avulsed tooth should be replanted immediately. This usually requires emergency personnel at the site of the injury with some knowledge of treatment protocol. Information should already be given to the people most likely to be on-site such as athletics trainers, school nurses, teachers and parents. However, failing this, the information can be given over the phone. The aim is to replant a clean tooth with an undamaged root surface as gently as possible and the patient should be brought to the clinic immediately. If any doubt exists and the tooth cannot be replanted, the avulsed tooth should be stored in a physiological medium such as saline for only a short period before replantation.11,12. Other suggested storage media includes Hanks balance salt solution milk and the patient’s own saliva.In the case presented here the father of the patient had immediately replaced the tooth in to the bleeding socket. The advantages observed by the author are;iControl of bleeding iiperiodontal ligament was not damaged iii Decrease in pain iv Less inflammation hence less swelling vPrognosis of the treatment was good.
If the periodontal ligament left attached to the root surface does not dry out, the consequences of tooth avulsion are usually minimal 13, 14. The hydrated periodontal ligament cells will maintain their viability, allowing them to reattach on replantation without causing any more than minimal destructive inflammation. In addition, since the crushing injury is contained within a very localized area, inflammation stimulated by the damaged tissues will be correspondingly limited, meaning that healing with new replacement cementum is likely to occur after the initial inflammation has subsided
Although there is reasonable evidence, to demonstrate soaking teeth in a tetracycline solution prior to replantation can increase periodontal healing and pulpal regeneration, there is insufficient evidence to recommend one particular drug, dose or duration. 6Hence the author did not feel the need to do it.                                                            
Pulpal necrosis always occurs after an avulsion injury. While the necrotic pulp itself is of no consequence, the necrotic tissue is extremely susceptible to bacterial contamination.Apexification or the conventional root canal treatment is done in a tooth that has an open apex or a closed apex respectively. Since the avulsed 21 in the case presented here was already endodontically treated the risk of any such infection is eliminated.
The type of splint and duration has not been shown to be a significant variable with regards to pulp or periodontal healing in human studies. There are many designs of splints in the literature and the most appropriate one depends on the facilities available. A cross over randomized controlled trial on ten healthy adult volunteers investigated four trauma splints wire composite splint, a button bracket splint, a resin splint and a titanium trauma splint. All splints allowed good periodontal health to be maintained and facilitated physiological. Whichever splint is chosen, it must allow some physiological movement of the injured tooth and care must be taken in application i.e. avoid impinging on gingiva or creating areas of stagnation which are inaccessible for cleaning. 2
Literature does not identify a specific time period for the duration of splinting but animal based studies suggest that a shorter duration of splinting would lead to less ankylosis. Therefore, the splint should remain in situ until the tooth is able to maintain its own position, 7-14 days. Once the splint is removed the tooth or teeth will still be mobile but cleaning of the tooth and gingival tissues is easier. Ideally splint removal should coincide with other treatment interventions e.g. pulp extirpation to minimize the number of visits patients need to make. It is for this reason that this guideline advises the use of a 7-14 day splinting duration. In the case presented above an Erich arch bar with 24gauge stainless steel wire was used as it was readily available. The splint was kept for an additional 2 weeks as the tooth showed mobility clinically and the author.
The key inferences the author has deduced from the article arei provide information to parents, bystanders and front line medical staff of the most appropriate treatment to provide which is to replant the tooth immediately, or if in doubt to place the avulsed tooth in any of the above mentioned appropriate media and attend emergency dental services. iiimprove the provision of emergency dental care with a clinician competent in making the diagnostic decisions and delivering the appropriate treatment iii the need for improved research on currently used and potential treatments for the future.
Conclusion.
Maxillofacial trauma persists as one of the few real emergency situations in dentistry and avulsion is one of them. Even though guidelines for the treatment of avulsion are laid down, quick intervention has proved to have the best prognosis. Oral health care professionals should spread public awareness of how on to handle the case of avulsed teeth, through the medium of campaigns, mass media etc.Dentists should always be prepared to give appropriate advice to the public about first aid for avulsed teeth.  Further more research should be carried out on those cases that have been replanted immediately.

References

  1. Goodisson D etal: Head injury and associated maxillofacial injuries. NZ Med J,2004; 117:1045.
  2. F.Day and T.A. Gregg; Treatment of avulsed permanent teeth in children;UK National Clinical Guidelines in Paediatric Dentistry.
  3. .Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries of the Teeth. Copenhagen: Munksgaard; 1994. Classification, etiology and epidemiology of traumatic dental injuries; pp. 151–77.]
  4. Martin Thorpe; Current and Future strategies for treating avulsed teeth;Dental Traumatology 2002: 18: 1–11
  5. Lars Andersson et al; International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth; Dental Traumatology 2012; 28: 88–96.
  6. Shiu-yin Cho, Ansgar C. Cheng;Replantation of an Avulsed Incisor After Prolonged Dry Storage: A Case Report; © J Can Dent Assoc 2002; 68(5):297-300
  7. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol1995; 11(2):59-68.
  8. Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol1995; 11(2):69-75.
  9. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to peri- odontal ligament healing. Endod Dent Traumatol1995; 11(2):76-89.
  10. Kinirons MJ, Gregg TA, Welbury RR, Cole BO. Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption. Br Dent J 2000; 189(5):263-6.
More references are available on request.

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